NPIMap

Organization Active NPI

La Maestra Family Clinic, Inc.

  • Federally Qualified Health Center (FQHC)
  • San Diego, CA
National Provider Identifier
1164167656
Registry record updated Apr 29, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LA MAESTRA FAMILY CLINIC, INC.
Practice address
4157 Fairmount Ave
San Diego, CA 92105-1609
Phone
(619) 285-7097
Fax
(619) 564-8140
NPI assigned
Apr 29, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 29, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tom Vu
Title
Executive Director
Phone
(619) 269-1292

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

4157 Fairmount Ave
San Diego, CA 92105-1609

Mailing address

4060 Fairmount Ave
San Diego, CA 92105-1608
Phone (619) 584-1612

Other names 1

  • La Maestra Community Health Centers Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050516000901 CA Part B Supplier - Clinic/Group Practice 7113968512 Receives reassigned benefits from 118 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: National City, CA; San Diego, CA; Lemon Grove, CA; El Cajon, CA
O20240404000658 CA Part A Provider - Federally Qualified Health Center (FQHC) 7113968512 Practice locations: San Diego, CA

Federally qualified health center certification: CCN A01851

Legal name
LA MAESTRA FAMILY CLINIC, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 6, 2024
Last certification
Mar 6, 2024
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Apr 29, 2013 in CA
Enrollment address
4157 Fairmount Ave
San Diego, CA 92105-1609

Other NPIs with the same Medicare PAC ID 9

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
La Maestra Family Clini40 organizations share this tax ID, including this one

Other organizations with this tax ID 39

Organizations that report the same tax identification number in the National Provider Directory.

View all 39

Locations

4157 Fairmount Ave
San Diego, CA 92105
Phone (619) 249-8255

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Pida Kongphouthone Individual Corporate DirectorBoard Member Jan 1, 2018
Graciela Putzoli Individual Corporate DirectorBoard Member Jan 1, 1999
Mark Boyer Individual Corporate DirectorBoard Member Jan 1, 2017
Louie Cazares Individual Corporate DirectorBoard Member Jan 1, 2019
Peter Both Gach Individual Corporate DirectorBoard Member Jan 1, 2022
Tom Vu Individual Corporate OfficerChief of Corporate Compliance May 6, 2011
W-2 Managing EmployeeChief of Corporate Compliance May 6, 2011
Zara Marselian Individual Corporate OfficerCeo Jul 22, 1991
W-2 Managing EmployeeCeo Jul 22, 1991
Samuel Mireles Individual Corporate DirectorBoard Member Jan 1, 1997
Charlene Castro Individual Corporate DirectorBoard Member Jan 1, 2002
Monica de la Torre Individual Corporate DirectorBoard Member Jan 1, 2013
Yessica Quiroz Individual Corporate DirectorBoard Member Jan 1, 1991
Christopher Ewald Individual Corporate DirectorBoard Member Jan 1, 2014
Robert Marquez Individual Corporate DirectorBoard Member Jan 1, 2019

Practitioners & affiliated clinicians

Practitioners 26

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 26

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1651190400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1651190400000",
    "number": "1164167656",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4060 FAIRMOUNT AVE",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921051608",
            "telephone_number": "619-584-1612"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4157 FAIRMOUNT AVE",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921051609",
            "telephone_number": "619-285-7097",
            "fax_number": "619-564-8140"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LA MAESTRA FAMILY CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-04-29",
        "last_updated": "2022-04-29",
        "certification_date": "2022-04-14",
        "status": "A",
        "authorized_official_last_name": "VU",
        "authorized_official_first_name": "TOM",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "619-269-1292"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "La Maestra Community Health Centers",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Diego, CA

Sources for this page

Verify at the official NPI Registry.